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Managed-Care Promotes Medicaid Fraud in Florida and the U.S.

Medicaid fraud is a serious offense. It may result in a federal conviction that can negatively affect your freedom, as well as your family and future. As health care costs grow to cover an aging baby boomer generation, Medicaid fraud is becoming an increasingly serious concern for the federal government. A recent report in Bloomberg Businessweek discusses a type of Medicaid fraud that has largely gone without prosecution. A U.S. Government Accountability Office (GAO) report was released last week to explain this alleged gap in the enforcement of Medicaid integrity.

Medicaid is a federal and state funded health insurance plan designed to assist poor Americans with medical expenses. While states are allowed some discretion over their Medicaid spending plans, the managed-care arrangement is increasing in usage. Under a managed-care program, the state pays private companies to insure citizens who are insured under Medicaid. This type of managed-care compensation arrangement is quickly becoming more widespread than the traditional fee-for-service model that’s been historically used.

According to the GAO, officials who were tasked with policing these payment arrangements chose to focus on fee-for-service payments, instead of managed-care programs. This occurred even though these arrangements accounted for 27% of federal Medicaid payments. The study reportedly combined information gathered from seven states, including Florida.

The Department of Health and Human Services responded to the report with assertions that the federal agency frequently conducts reviews of state managed-care programs. A representative also reportedly stated that the agency provides training for state workers and promotes best practices in an effort to prevent fraudulent activities.

According to the GAO report, the problem lies in the complexities of managed-care payments. Carolyn Yocom is the director of health care with the GAO. She is quoted in the article as saying that Medicaid “has not traditionally been very transparent, nor has it been very easy to see where the money goes.” She further stated, “The visibility of what happens is once-removed, because of the managed-care entity itself.”

What This Looks Like In the Real World

Managed-care fraud manifests in the following ways:

  • More enrollees, with fewer service expenses equals more money for the managed-care companies;
  • Companies drops clients with serious illness and greater medical needs without cause; and
  • More “desirable” clients are threatened and pressured into signing up with managed-care companies and accepting unnecessary services.

Anyone involved in these practices can be charged with Medicaid fraud and prosecuted in federal court.

There are numerous types of possible Medicaid fraud. Patient beneficiaries, health care professionals and service providers can all be perpetrators of Medicaid fraud. Patients who provide false information to gain health care services are committing fraudulent behavior, as are physicians billing for medically unnecessary procedures. The potential consequences of Medicaid fraud are serious and require the assistance of a skilled attorney.

If you or a loved one has been accused of Medicaid fraud, contactMiami based Ratzan & Faccidomo, LLC. who have decades of combined experience. Call the office today at 305-600-3519 for a confidential and free consultation.

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